Literature review: implementation of electronic medical records what factors are driving it? Title. Citation. Issued Date 2009

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1 Title Literature review: implementation of electronic medical records what factors are driving it? Author(s) Vu, Manh Tuan. Citation Issued Date 2009 URL Rights The author retains all proprietary rights, (such as patent rights) and the right to use in future works.

2 Abstract of the thesis entitled Implementation of Electronic Medical Records- what factors are driving it? Submitted by VU MANH TUAN for requirement of the degree of Master of Public Health at the University of Hong Kong in August 2009 In this review, studies related to implementation of Electronic medical records conducted from in less developed countries were examined. Despite of limited number of papers met inclusion criteria of this review, findings were collected. Findings were synthesized into two mainstreams as negative and positive drivers to EMR implementation. In each mainstream, the results were also revised as measured (findings were withdrawn from arithmetic data analysis) and perceived (findings were described by participants in study). The result shows only a few studies attempted to measure barriers and benefit that those who implemented EMR might encounter. Instead, most of studies are descriptive research which may not provide strong evidence to encourage implementation of EMR in developing world. Many pilot studies were included in this review, small and large, but they shared the same point that EMR systems implemented in developing countries, first, only served a certain specific condition and setting of health care system; second, were initiated mostly by NGOs or projects supported by developed countries. This might explain discreteness and narrowness of EMR systems applied in less developed regions. Keywords: Electronic Medical records, implementation, barriers and drivers

3 LITERATURE REVIEW IMPLEMENTATION OF ELECTRONIC MEDICAL RECORDS WHAT FACTORS ARE DRIVING IT? VU MANH TUAN Master of Public Health Project The University of Hong Kong Faculty of Medicine Community Medicine Department

4 DECLARATION I declare that this project represents my work, except where due acknowledgement is made, and that it has not been previously included in a thesis, dissertation or report submitted to this University or to any other institution for a degree, diploma or other qualifications. Signed:.. (Vu Manh Tuan) 3

5 ACKNOWLEDGEMENTS I would like to express my many thanks, primarily, to my supervisor, Dr. LM Ho for his guidance and support throughout the preparation of my research project. I also would like to thank Dr. Janice M Johnston for her advices to my project. Without these insightful and valuable comments, the project would not have been possible. Overall, I would like to thank all professors, tutors for their great lectures that have given me knowledge and skills to conduct this research. I also want to take this opportunity to say thanks to teaching assistants, and administration staff, especially Joyce, who have put much effort for Master of Public Health program and students. I also want to send my appreciation to all of my friends. Over past year, I also enjoyed much friendship and encouragement from my classmates in MPH program. Without them, my last year would not have been so meaningful and memorable. Finally, I would like to express my gratitude to my parents who are always supporting me both financially and spiritually to go till the end of program. 4

6 CONTENTS LIST OF TABLES...6 ABBREVIATIONS...6 BACKGROUND...6 WHAT FACTORS INCLUDED IN THE RESEARCH?...8 ARE ELECTRONIC HEALTH RECORDS, ELECTRONIC MEDICAL RECORDS AND PERSONAL HEALTH RECORDS INTERCHANGEABLE TERMS?...10 RESEARCH QUESTION:...13 RESEARCH STRATEGY: Identification of publications: Inclusion/exclusion criteria: Databases: Methods of study...14 RESULT:...16 DISCUSSION:...26 IMPLICATIONS...30 LIMITATIONS...31 CONCLUSIONS...31 REFERENCES:...33 APPENDIX:

7 LIST OF TABLES Table 1: Distribution of references according to exclusion and inclusion criteria...17 Table 2: Articles included in study...18 LIST OF FIGURE Figure: Summary of positive and negative drivers toward EMR implementation ABBREVIATIONS AIDS: EHR: EMR: HIV: Acquired Immune Deficiency Syndrome Electronic Health Record Electronic Medical Record Human Immunodeficiency Virus HL7: Health level 7 IT: NAHIT: NGOs: PHR: TB: Information technology National Alliance For Health Information Technology Non-government Organizations Personal Health Record Tuberculosis BACKGROUND Information technology has offered great advantages to improve efficiency and effectiveness in work of many industrial fields, e.g. commercial business, 6

8 airline, manufactures, and so on (1). Despite well-established evidence seen in other industries, the adoption of Information Technology in health care organizations has been growing slowly (2). Such delayed implementation implies some certain obstacles are dismaying willingness of health care provider to take part in this movement. Computer-based techniques have been introduced to health care throughout decades, e.g. computerized physician order entry system, clinical decision support system, picture achieving and communication system, laboratory results management, etc. Among these, Electronic Medical records (EMR) is drawing much attention from society, professionals, managers as well as policy-makers (3). This reflects recognition of EMR s role in improving health care quality one of the fundamental concerns in health care services. EMRs are expected to ameliorate problems that paper-based records encountered, e.g. inaccuracy, illegibility, incompleteness, expensive storage, difficult to retrieve needed information, discontinuity of care or the service would be duplicated and fragmented patient information if this was not shared between health sectors (4, 5). On the other hand, the EMR repository will create a huge database that makes better use of patient s information. In addition, EMR systems are particularly important when patient-centered concept of health care is prominent and integration of health care information about patient care becomes imperative. Hannah et al. (2005), in her report which reviewed a broad view on EMR system implementation studies, indicated some potential benefits that EMR brings to patients and care providers, including fewer medical errors, more efficient health care delivery, reduced costs, 7

9 streamlined clinical workflow, better disease management, improved quality, and improved data tracking and accessibility (6). These benefits of EMR are believed to be solutions enabling quality of care being maintained in condition that health care organizations are overloaded and facing emergence of aging population, mutation of infectious disease, epidemiological transition, technological development, and so on. Not only developed but less developed countries are now sharing relatively similar concerns. Therefore, benefits from EMR implementation have been shown in developed countries may open opportunities that they, also, can be achieved in less developed countries. In contradictory to developed countries where amount of EMR implementation research is considerable, the research activities of this kind are quite a few in less developed countries. It is necessary to review factors influencing decision makers with regard to the implementation of EMR in less developed countries. WHAT FACTORS INCLUDED IN THE RESEARCH? Implementation of EMR in any setting requires readiness of change in structure, culture and workplace design as well as capability of physicians (7). In fact, a high number of failures of EMR implementation have been seen elsewhere. Even though the evaluation of success or failure might be very subjective as one s failure can be success of the other due to different perspectives (8),(for example, R.Heeks had tried to define success and failure by categorizing health information system into 3 ways: the information system is completely abandoned after implementation; the information system does not meet set-up goals; and the 8

10 information system obtain what have been set)(9)few research has been done showing users resistance, low acceptance rate, private and confidential issues and poor compliance or insufficient preparation as the main leading causes of failures (10, 11, 12). They emphasize the argument of a managerial theory introduced by Wilfried Krüger. According to his Ice-berg theory, it points out many managers, when decided to deploy any intervention, they tend to consider Issue Management which means cost, quality and time lying above the surface. Unfortunately, major part of the iceberg is below the surface including interpersonal (e.g. beliefs and perceptions lead to attitude) and political (e.g. power and policy lead to behavior) issues which are dominant upper part and main barriers to change (13). In organizational change theories, these issues were addressed in different perspectives taken place (14). For example, in systems theory, it considers sequences and consequences of change that change in each part of organization relates to change of a whole system, and all aspects in organization are equally important (15). While, in organizational development theory, human is a center of organization, hence level of individual agreement to change of organization will play the key role (16). The complexity theory also emphasized human role, but focused on interaction between individual and organization which addressed both formal and informal relationship (17). Therefore, to simplify discussion of findings in this review and to address comprehensively issues related to implementation of EMR, I am focusing on two mainstreams: - Positive drivers or promoters contain factors that encourage EMR implementation, and 9

11 - Negative drivers or hidden barriers contain factors that discourage or impede EMR implementation. ARE Electronic Health Records, Electronic Medical Records and Personal Health Records INTERCHANGEABLE TERMS? In order to find and include valid and pertinent studies, understanding of term used in research process is an essential. Lack of standard definition might play unexpected role in implementation process (18). We have heard researchers used Electronic Health Records (EHR), Electronic Medical Records (EMR), and Personal Health Records (PHR) in many studies, the question is: Do they really bear resemblance to each other? This has raised a debate about definition of each among experts and professional users who are very diverse in specialty, positional level, and dissimilar backgrounds. Only a few institutions are trying to define and distinguish these terms. As EHR definition of Health Level 7 (HL7) a health care standards development organization EHR is a secure, real-time, point-of-care, patient-centric information resource for clinicians (19) while NAHIT (National Alliance for Health information technology) defined EHR as an electronic record of health related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed and consulted by authorized clinicians and staff across more than one health care organization (20). The second definition of EHR (by NAHIT) accentuates clearly who are responsible for EHR but the first one is more general. From two definitions, EHR is an effective 10

12 tool to aid clinician communicate and exchange information which might decrease waiting time (e.g. patient journey through a health care system) and gaps in knowledge of patient health among care providers. EMR, on the other hand, might be misunderstood as if it includes EHR because of its popularity. In fact, however, they are different and not interchangeable from definitions found. The American Health Information Management Association noted that definition of EMR is similar to EHR, but one key point distinguishes EHR and EMR is EMR is used by authorized staff or clinicians within one organization only. Although NAHIT has its own definition as an electronic record of health-related information on an individual that can be created, gathered, managed and consulted by authorized clinicians and staff within one health care organization (21), two definitions stated clearly EMR is used in a single organization. The EMR consists of information that a conventional record (paper-based) does, for example, results of laboratory tests. PHR, on the other hand, is easier to differentiate from two terms above in its literal meaning. An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources while being managed, shared and controlled by the individual is called personal health record (21). The definition, however, actually looks for an optimal condition that people will take longer time to attain. Information contained in PHR might or might not be similar to EHR or EMR, for example it can include family or personal health history like allergy, immunization records, physicians whom patients usually see when they are sick, 11

13 and so on. In short, EMR and EHR might be used interchangeably, but EMR serves a single organization, while EHR serves a larger scale entire healthcare system. This is the only point making EMR and EHR different. Unlike EMR and EHR, however, PHR is used and modified by individual, not a professional care provider. 12

14 RESEARCH QUESTION: What are factors driving implementation of EMR in less developed countries? RESEARCH STRATEGY: 1. Identification of publications: In spite of clarification noted in introduction section (see page 4-6), it is necessary to be aware that EHR, EMR and PHR term might have been used arbitrarily in previous studies, hence they were still included in search terminology so that I can avoid missing out any relevant studies. Searching terms below were used to identify relevant papers: - electronic medical record* AND developing countr* OR less developed countr* - electronic health record* AND developing countr* OR less developed countr* - personal health record* AND developing countr* OR less developed countr* 2. Inclusion/exclusion criteria: Researches published from were selected. A reason to limit publications in such period is findings in studies conducted before 2000 might not be applicable in current context in which informatics technology would have changed drastically since past decades. Duplicate references were excluded, as were references without abstracts and full-text. Those did not specifically either relate to health or focus on electronic medical record, both were excluded. Commentary; editorial or news/presses; documentation, summary executive and report of conferences or any national/international policy and announcement and books, as well as papers 13

15 described intentions to implementation, but not implementation experiences were not included. The studies could be acceptable regardless of qualitative or quantitative research and health care setting. I also do not include these studies which are conducted in developed countries, published in non-english language, or unpublished. The studies should state clearly what study design and method applied in the paper. Developed or less developed countries were categorized according to latest documentation published by World Bank in July, 2009 (22). 3. Databases: The data sources include PubMED, EBSCOHOST the available electronic databases in HKU, and Cochrane. In each database, the search terms were searched. 4. Methods of study Inclusion and exclusion criteria were complied throughout the selection process to ensure studies selected able to answer research question. A checklist including 5 steps in selection process was set to exclude studies irrelevant. - Step 1: Title of studies would be skimmed based on results run out from the search terms in each database. If following terms health informatics, electronic medical records, electronic health records, personal health records, computerized, health IT or other informatics-related term appeared, the study was recorded in the database. - Step 2: Inclusion and exclusion criteria helped to filter ineligible studies. For example studies published before 2000, and without abstract. - Step 3: Abstracts of these eligible studies will be reviewed according to criteria: 14

16 clear information about study design, outcomes and whether function of computerized medical records mentioned in study links to function of electronic medical records. Those studies did not satisfy criteria were subtracted from database. Information collected from these studies will be simply synthesized in a database format prioritized in order from the most relevant to the less relevant. - Step 4: To ascertain validity and fend off selection bias, all studies extracted from step 3 will be examined by a study checklist (see appendix p.33). The checklist will screen description of validity, applicability, importance of each reference. Inclusion and exclusion criteria were, then, re-checked in this step to completely separate out unqualified studies. References cited in these studies were traced back and might be included in the review if eligible. - Step 5: Information gathered in step 4 will be synthesized systematically and elaborated by summarizing all the findings into 2 mainstreams: Negative and Positive factors. The review includes both qualitative and quantitative studies, hence, not all findings will be measured statistically (i.e. in arithmetic), but will be described as events, opinions, reasons or explanations. In order to clarify differences between these findings, after allotting to Negative and Positive columns, they are also appointed under 2 subsets namely Perceived evidence and Measured evidence. 15

17 RESULT: The search process resulted in 421 publications which the titles contained relevant terms. After studies selected in step 1, step 2 excluded 174 from the list, of which 103 have no abstract and full text available, 7 published in Chinese, Japanese, Italian, Spanish, Germany and Norwegian, 66 were publications of expert s opinion, news or presses, editorial and book chapters. Step 3 was continued and took out considerable number of those studies irrelevant (80) and those were conducted in developed countries (148). Irrelevant studies mentioned about innovation of EMR technique, other compatible soft-wares, and especially EHR or PHR application. Studies conducted in the United States of America account for nearly 90%, the rest share between Korean, Japan, German, Australia, and some other developed countries. Finally, there were 17 (about 4%) studies included in step 4. This is the last step to let in the most relevant studies to answer the research question, and out of 17, 6 other articles did not provide a clear description of study or fail to fill criteria set out for critical appraisal. The result was shown in table 1. (see next page) 16

18 Table 1: Distribution of references according to exclusion and inclusion criteria Total references identified: 421 Excluding: No abstract and full-text available 103 Non-English language 7 Irrelevant 80 Experts opinion/magazine/news/book chapters/editorial and commentary Conducted in developed countries Included in step 4 17 Critical appraisal excluded 6 Final papers selected 11 Of eleven studies selected in final stage, studies conducted in Kenya account for about 45% (5 out of 11), another countries represented in the research are Cameroon, Haiti, Peru, and India. One study was a product resulted from a survey carried out in 15 countries of Africa, South America and Asia. Among these studies, only 1 study used the term Electronic health record instead to describe the function of Electronic medical record, however its definition of EHR was quite ambiguous between EHR and EMR. 17

19 Table 2: Articles included in study *Term EHR was used instead of EMR Author Year Country Healthcare setting Study design Focus Kaliyadan et.al India Dermatology Comparing between Application of EMR (23) using EMR and paper-based system for entering information Foster et.al. (24) developing HIV/AIDS care Survey and data Data quality and patient countries of analysis management Africa, South America and Asia Lober et.al. (25) 2008 Haiti HIV/AIDS care Description and data Design, development and analysis implementation of EMR system Fraser et.al. (26) 2006 Peru Tuberculosis treatment Description Evaluation of impact and cost of EMR implementation Diero et.al. (27) 2006 Kenya Acute respiratory Description Application of EMR diseases care Mamlin et.al. (28) 2005 Kenya HIV/AIDS care Description Design and implementation of EMR system Kamadieu et.al. * 2005 Cameroon Primary care Descriptive and Design and implementation of (29) observational study EHR system Siika et.al. (30) 2005 Kenya HIV/AIDS care Description and data Application of EMR analysis Tierney et.al. (31) 2002 Kenya Primary care Description Application of EMR Anantraman et.al India Maternal and Child Description Application of EMR (32) care Terry et.al. (33) 2000 Kenya Antenatal and Child Description Design and implementation of care EMR system 18

20 Most of the publications selected describe application of EMR in setting of infectious disease prevention and treatment, especially HIV/AIDS and TB or acute respiratory for instance; and primary health care or ambulatory care. Figure: Summary of positive and negative drivers toward EMR implementation 19

21 Supporting decision in drug dispense, treatment (31); long-term follow-up and prolonged schedule of treatment Measured Enabling out-reach services e.g. appointment checking, home visit, reason of missing clinics (30) Availability of routine outpatient s consultation data (29) Time-saving from easily retrievable digital data (30), and increasing duration of consultation in a long-term benefit as physicians get used to with the entry system (23, 29) Positive drivers Quality (23, 24, 25, 26, 31) and continuity (24, 26, 28) of care improved through better data management e.g. checking patient adherence (30), reducing missing and erroneous data(23, 27), data modeling (25, 28) Satisfaction of patients and care providers (31, 32) Convenience (23) Perceived Better patient flow management (29) Potential developing national and international report (25) Increasing self-esteem and reputation of physicians; and recognition of best practice (29) The EMR system can be a platform to facilitate appliance of another advanced techniques (23) Acceptance of users depends on how familiar with computers users are (23, 31) 20

22 Cost-effectiveness has not been obtained or evaluated systematically (25, 30, 32) Measured Limited computers and resources (29, 25, 24) High turnover rate of personnel (29) Shortage of technical support (23, 25, 29, 31, 33) Non-standardized classification and definition in coding system (24, 27, 28, 29) Negative drivers Patient and physician relationship/communication interrupted (23) Geographical disparity of health care sectors (30) English is main language in design EMR system (32) Unstable electrical power provision (25, 31) Work flow interruption (23, 26, 32) Dependent budget and funding from external resources (33) Perceived Low capacity, lack of training, encouragement or incentive of change, shortage of manpower (23, 24, 29, 30, 32, 33) Local needs: assessment is not usually studied before application (33, 25, 23) Logistical support: design planning, software development (23, 33) and workplace design (26, 31) Data security and confidentiality (32); no standard (validity and applicability of standards in developed countries) (30) Constrained competition of primary care data with actual public health emergencies preclude EMR adoption in primary care (29) 21 Privacy: for example HIV/AIDS or TB patients encountering stigma which hinders them to approach healthcare programs or sectors (31)

23 The concerns driving EMR implementation were listed in table 3. Implementations of EMR in the studies have pointed out numerous benefits for physicians, managers and patients. Positive benefits included, for example records of drug usage, diseases, diagnosis tests which might help to improve quality and continuity of care, health policy, patient safety and medical research (23, 24, 25, 26, 31), or to check the adherence of patients (30); restructured data system reduces time to retrieve information of patient and to facilitate reminder system (26, 30); reducing missing data or erroneous and inconsistent data (23, 27); developing data modeling (28, 25); potential developing of national and international report (25). As data management was improved, it brings about time-saving (30), that allows physicians spending more time on consultation (23, 29) and examining their patients, thus patient satisfaction and quality of diagnosis and examination might be gained (31, 32). In addition to the quality concerns, reputation and pride of physicians who applied EMR are increased and somewhat recognizes their good practice among others, this subtle point was noticed in the study of Kamadjeu et.al.(29) and could play an important role in EMR adoption movement. Moreover, with EMR systems set up in some less developed countries, it has made such an auspicious start that enables further development of EMR going along and compatible with other related advanced-techniques (23) in the future. Unfortunately, potential benefits of EMR system, however, have met negative drivers that could impede or deject willingness to apply such technology. In professional worries, lack of technical support is one of the most mentioned topics among studies namely hardware, software and other device malfunctions 22

24 (23, 25, 29, 31, 33); and workflow interruption (23, 26, 29, 32) described in some studies like a complex procedure of a patient getting in a public health care sector (e.g. a patient supposes to go from triage stage through consultation, laboratory and pharmacy room but in developing countries patients do not have habit to finish all the stages instead to go directly to any room match their situations, such activities of patients would result in difficult to collect patient information) (29). Poorly accepted, inconsistent and non-systematical standardization of definition /indicators/measurements or classification codes creates more work for recording task (24, 27, 28, 29). A very interesting finding is that unstable electricity provision is one of considerable factors interrupting operation of EMR systems (25, 31), therefore additional investment on back-up system UPS (uninterruptible power supply) - is necessary. Such additional cost would affect decision of managers who already knew how expensive the original system is. Economic analysis of EMR implementation seems not getting strong evidence in either positive or negative aspects. There are only 3 studies mentioned evaluation of cost against effectiveness or benefits (25, 30, 32), but the results did not show specifically. Yet EMR system is available, low capacity (low computer literacy, shortage manpower) of staff and absence of appropriate incentive or encouragement might discourage good practice (23, 24, 29, 30, 33). A perfunctory preparation before implementation (23, 26, 31, 33), a paucity of independent funding channel (33), and poor facility/infrastructure (24, 25, 29) to maintain and well function EMR system are other barriers in managerial issues. Besides subjective reasons, geographically disproportional 23

25 distribution of healthcare sectors might interrupt the data management process e.g. encounter forms are transferred from remote areas in which road may not be well constructed, especially in rainy season; or because of data interruption, late-updated time-being of data set might not support benefits of EMR system brought to care providers, managers or researchers (30). As noted in introduction part, the publications included in this research reflect that cultural and habitual factors in an organization or among staff are paid less attention than managerial issues. One paper addressed shortage of well-trained personnel in rural area or physicians migration drain to developed countries (32), while another one added in that data collection culture is a critical challenge (29). EMR system set up in less developed countries mostly imported from developed countries, thus English is usually defaulted as its language which might cause inconvenience in usage (31). Private information, together with confidentiality, are issues that both physicians and patients are considering in un-well organized sectors, especially HIV/AIDS and TBs patients who still bear stigmatized attitude from society (31). Despite importance of local needs assessment on which system design depends, findings from the publications indicated that needs assessment were not always on the top priority in such EMR intervention. It could be because financial support from developed countries was not sufficient and of an assumption that successful model in developed countries can be copied and deployed in developing countries. Thus, it causes, on one hand, unnecessary implementation or inefficient intervention and on another hand, the situation that frustrates physicians and patients (33, 25, 23). 24

26 Overall, the result table highlights one point very important. The number of findings columned in measured evidence is far behind comparable to perceived findings. This might be the gap that researchers need to bridge in developing world. 25

27 DISCUSSION: Both specific and general keywords were employed in search strategy to look for relevant publications. However, none of publications focused merely on or tried to measure particular issues that are leading to EMR implementation. The evidence points out current studies are attempting to describe what appliances and how process and progress stage of the system rather than to analyze association between causes and consequences within it. The results shown in table 2 indicate ten out of eleven studies are descriptive researches and most of findings were perceived rather than measured. The low rate of studies matched our criteria may be explained by two reasons: first is only a few EMR systems has been implemented in developing countries and most of them depend on external funding channels; and second is because of low availability of EMR system, it resulted in low research interest in this field. Although every country has its own cultural, economic and political features, but developing countries located in the same continent e.g. Asia, or Africa, or South America might share similarity in some extents. For example, most of publications were pilot studies and EMR systems, majorly, were subsidized by NGOs or developed countries to support a specific health issue of a single local. The result shows that investments in less developed countries are usually insufficient, taking unstable electrical power, lack of training, or poor facility as examples. They reflect two issues. Firstly, less developed countries have not framed appropriate strategic plans going through needs assessment, implementation and evaluation. Second one is highly depending on budgets from foreign countries will be a key 26

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